Parents' Guide to Variation and Exceptionality

Charles Mike Rios MD.

THE BIG PICTURE

To begin I would like to suggest some ways to prepare your mind to understand the text you are about to read. Some of us are able to comprehend text by just reading and others benefit from some strategies to visualize the subject. I would like to suggest a couple of visual strategies. One can visualize overlapping circles. Each circle can represent a separate ability, a separate problem or differences. The circles can influence other circles, hence they overlap. Another visual metaphor is a car. Having driven a 1966 Mustang as my daily driver from 1978 till the mid 1990's this is an excellent visualizer regarding parts working and not working and how one affects the other. A dead battery can stop you cold but a frayed battery cable can also do this or a gunky battery terminal can as well. Also, all three parts of the battery can malfunction: the battery, the cable and the battery terminal. Let's get started! First, the major parts:

LANGUAGE

Language is the ability to receive another's words for understanding (Receptive Skill) and the ability to string your own words for expression (Expressive Skill). There are many subparts here which will be discussed in the language chapter. When Language is strong we see kids who can persuade, tell stories, argue and perhaps read at an early age. When this Language is weak children may be more aggressive as they learn to be more demonstrative because their ability to use words to argue and persuade are not strong. Two areas that are not typically associated with language skills include

Phonological Awareness which is the understanding of the beat to language. Examples include rhyme/onset, syllable separation and words that are separated by one small sound difference like bat and cat. This understanding in a 4-5 year old child predicts success with reading.

Pragmatic language overlaps with social skills and refers to the use of language to facilitate social relationships. The developmental area of memory also has a language component and is referred to as auditory memory.

VISUAL SPATIAL ABILITY

Visual spatial ability allows the child to recognize and manipulate shapes, designs, right, left, top and bottom. When this ability is strong we see the puzzle masters, future artists and engineers. Children with visual spatial weaknesses struggle with left/right. They have great difficulty with learning conventional rotation of letter and number forms. Often they have handwriting weaknesses due to weak visual spatial awareness. Handwriting weaknesses can also overlap with other developmental areas like memory for fine motor movements or in the motor area itself , for example, poor eye-hand coordination. Children who are weak in math often have difficulty visualizing the number line (0-10) and its order of magnitude (10 to100 is the same number line just increased by 10)

SOCIAL ABILITY

Social Ability allows us to use non verbal social skills like gestures (shrugging shoulders, using hands for describing); making eye contact when spoken to; making eye contact to express oneself, for example looking at parent and pointing; reacting appropriately to conversation (look it's raining); using inanimate objects to represent real people like appropriate play with "little people" or action figures. Strengths in this area act like a magnet for peer relationships and weaknesses foster isolation and misunderstanding. Good social ability is aided by strong language skill and worsened by language weaknesses. Strong impulse control and memory skill aids social abilities. Obviously, children with Autism Spectrum Disorders have weaknesses here but so do impulsive ADHD children and mood disordered children.

MEMORY

Memory partially consists of visual memory, auditory memory, factual memory, procedural memory ,memory for events, motor memory and phonological memory. There are a lot of different types of memory. A child can remember family events, movies and vacations but has difficulty recalling dry facts like math tables and dates in history. A child can talk forever about "Thomas the Tank Engine" or "Star Wars" but cannot follow a two step instruction. There is short term and long term memory. Memory has its tentacles in all the developmental areas. Think of overlapping circles here. Examples include good auditory memory for stories or sounds in words. A good visual memory for shapes/forms/direction in space are examples of visual-spatial strength. Motor memory allows one to write an "E" and make it look the same every time and make it quickly. Golfers attempt to commit their swing to motor memory in order to be consistent.

MOTOR SKILLS

Motor Skills refer to balance, coordination, strength and memory (motor). These components are used for fine motor skills like handwriting/needlework and gross motor skills like running, jumping , throwing and dancing.

The motor area in recent years also includes one's ability to regulate their sensory relationship to the world. One learns to differentiate taste, texture and pressure as it applies to the sensory centers of touch, taste, smell, hearing and visual modalities. Many young children who will later be identified with Autism Spectrum Disorders, ADHD, Mood disorders and Learning disorders have sensory issues when they are very young. They may overreact in the form of fear and irritation with certain noises like vacuum cleaners, dish washers, airplanes flying overhead and even car engines. They may reject certain foods due to their textures. They may insist on certain types of clothes like shorts and sweaters when it is inappropriate due to the temperature.

ATTENTION

Attention is the ability to focus, use planning, monitor oneself, learn from experience and reduce or turn up our activity or energy level according to what is called for each and every second in the present. Many young children as they approach early childhood are suspected of having Attention problems due to their hyperactivity when they are compared to their peers for the first time in preschool or daycare settings. They are very restless, constantly on the go and very impulsive. They often place themselves in danger. Examples include jumping from high places or running away from parents in malls or on the street. The ability to modulate your energy level according to the situation and use your experience from past mistakes is the issue here. Thus, memory is a strong component here. Children with Attention problems do not learn from experience. Weak Social skills are often seen when they interact with peers. They are considered "loose cannons" as they often intrude on a peers' personal space. They forget the rules of the school room by failing to ask permission to leave, blurting out constantly or ignoring teacher reminders to transition to another activity.

Later as children age other subtypes of the disorder may be recognized. Many non-hyperactive children with ADHD may not be recognized till middle school when their daydreaming, procrastinating ways and poor planning skills result in missed homework and last minute attempts to complete projects that have been on their to do lists for weeks. This developmental difference often does not come alone. This means it is often associated with other issues like Language, Mood, Memory, Sensory, and Social differences.

MOOD

Mood is determined by one's ability to control fears, worries, irritability, obsessions and anger. Young children, experts are beginning to understand do not manifest adult like symptoms of depression, anxiety or bipolar disorders. However it is becoming clear the children who will later develop these mood differences are different even at an early age. Often these children have Sensory issues. The length of their tantrums and the severity of the tantrum provide clues to emerging Mood Differences. Potentially mood disordered children often have tantrums that last more than 30 minutes and often several per month that last over an hour. This is in contrast to regular children who stay upset for less than 20 minutes, tops.

THE PRODROMAL BIPOLAR CHILD

Mood disordered child also will tend to destroy property and physically attempt to harm by choking, hitting, kicking and biting. Some mothers have told me the child destroyed her collection of figurines or I have been told the parents fear for younger sibs or family pets when he/she is in a severe meltdown. It is becoming clear that children with these above differences may later suffer from depression, anxiety or bipolar disorders.

OKAY, THESE SEVEN DEVELOPMENTAL AREAS:

all of which are deep and complex will help you understand your child's strengths and weaknesses. This understanding gives you the power to stoke the embers of strengths and both attempt to fix (remediate) and bypass the weaknesses. Success in life is to strike a balance between our strengths and our weaknesses. Our short lives are a reflection of this duality. Great minds have referred to the light and the shadow; ying and yang and challenge us to find balance to achieve happiness and peace. Many of you already know after reading this 1st chapter what your child's issues are about. You are saying "AH HA" the "Game is Afoot" to coin a great detective. You are beginning to untangle those threads that are so interwoven around each child. Feel free to skip to the particular chapter or chapters that address your concerns. Each chapter related to these seven developmental areas will go into more detail and make recommendations of how you can intervene to help your child.

IMPORTANT CONCEPT #1:

These developmental areas are often in groups. That being said let us look at some examples. Autism Spectrum Disorders (ASD) consisting of Autism and Pervasive Developmental Disorders, .NOS (omit Asperger Disorder for the example) have three of the above developmental areas involved. A group of circles involving Language, Motor/Sensory and Social differences define this disorder.

Attention Deficit Hyperactivity Disorder (ADHD) has involvement of attention, memory and 30 to 40 percent have language and/or mood issues. Dr. Daniel Amen a Psychiatrist has used brain imaging scans to show six different ADHD brains. When one reads his description of the different types of ADHD you can visualize overlapping circles. Types 1, 2, and 3 are combinations of core ADHD symptoms for example with or without hyperactivity. Types 4, 5, and 6 appear to also include varying aspects of mood problems.

Children who are later identified with Learning Differences like Dyslexia (Reading Disorder) often have issues with Fine motor skills involving eye-hand coordination or motor memory causing a handwriting weakness with the ability to combine speed with accuracy. We call this Dysgraphia. Up to 30 percent also have Attention issues.

Mood disorders characterized by explosive anger, aggression, and irritability often can overlap with learning disorders, ADHD, Autism Spectrum Disorders and even other mood issues like obsessive compulsive issues.

IMPORTANT CONCEPT #2

A concern of parents is at what age can children be diagnosed. Many nationally recognized experts like Dr. Stanley Greenspan and Dr. Terry Brazelton recommend paradigms that stress individual developmental differences rather than a label early on. For example, describing levels of social ability, attention and sensory issues rather than trying to fit a label like ADHD or Bipolar. Eventually as a child ages, the inevitable label if developmental differences are still present, will be applied but at a young age of 2-4 years we may be observing early stages of a disorder or maturation issues that will become resolved. Many developmental stages have varying timelines of normality. Some children are reading at age 4 and others will not read until age 8. So a developmental describing approach seems to make great sense for young children. That being said,

DO NOT TAKE A WAIT AND SEE ATTITUDE!!!!

If evidence seems to be mounting, for example, the child is not consistently responding to his name when you address him/her or if daycare facilities are commenting about the level of hyperactivity and aggression, then you must intervene. Parents of multiple children are often quick to pick up on differences. "None of my others were anything like this" and seek professional guidance. Even if you only have one child, look into your family tree. If many of your nieces and nephews have needed speech-language therapy and your child is not talking like peers then seek intervention. If your child is having severe meltdowns where he destroys property and puts himself or others in harm's way and there are many adults in the family who have been diagnosed with bipolar or depression then seek help.

Two last important issues I want you to read and reflect on is this:

IT'S NOT YOUR FAULT!!

All of us have our issues okay. Sometimes we can trace these to our family tree (genetics) but sometimes we simply cannot know. It's your job to refrain from blame or guilt and help your child move forward to achieve balance which is the key to happiness. All of us are going to have successes and failures. How we handle the failures is probably more important than the successes. So no blame!

YOU ARE NOT ALONE!

There are thousands of parents who have children with your child's same exact issues. So seek out a parent support group. Go to the meetings ask questions and network. You don't have to reinvent the wheel okay. You will always meet someone ahead of you that has already experienced what you are going through right now and can help give advice to get you past the present circumstances.

WHAT DO YOU NEED TO BRING WITH YOU TO THE DEVELOPMENTAL APPOINTMENT?

These recommendations mainly reflect the visit to the physician.

Family History.
Ask your parents and grandparents for information regarding developmental issues among family members. Especially important are family members with intellectual delays, mood disorders, ADHD and learning disorders.

Birth History.
Were there issues in the prenatal period like hypertension, diabetes or bleeding. Was oxygen required at birth for the newborn and was time spent in a Neonatal Intensive Care Unit? Were there any feeding problems or seizures at birth? Were Xrays, Ct scans or MRI's performed?

Developmental History.
When did you first become concerned regarding your child's development and why? Was there REGRESSION of skills? Have there been intolerances to foods. Has the infant or young child received any previous services like Early Childhood Intervention (ECI)?